Transcript Slide 1

Performance incentives in the
high income countries – key
issues and lessons learned (for
the low-income countries)
Riku Elovainio
World Health Organization, Geneva
INCENTIVE SCHEMES AND PERFORMANCE OF
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Clermont-Ferrand – 17 Dec 2009 (Session 5)
Performance incentive schemes in
high-income countries
Overview
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Performance Incentives in HICs and LICs –
same underpinning
 Performance Incentive (PI) schemes in high-income countries
(HICs) have a similar history than in low-income countries (LICs) =
implemented mainly in 2000's
 Same rationale : direct payment incentive to influence provider
behaviour
 = same underpinnings than in LIC : (principal-agent relationship
and the effect of extrinsic motivation)
 BUT – a lot of differences: different context, different objectives 
different implementation strategies and mechanisms
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Performance Incentives in high-income
countries – the basics
 Explicit incentives that add to the system (implicit)
incentives
 Often linked with other reforms (ex. public reporting)
 Bottom-up approach (projects, programmes) for changing
provider behaviour
 System wide ambitions only in UK (maybe France)
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Overview – Where are the experiences ?
 USA
– P4P "movement" related to a reaction to the IOM report "Crossing the
Quality Chasm" (2001)
– US patchwork context – P4P schemes have taken several forms
– Ex. CMS has several different programs; IHA in California; Bridges to
Excellence; several smaller schemes
– In total 248 P4P schemes with different scope, different target and different
indicators (some providers are involved in several schemes at once)
 UK
–
–
–
–
QOF = Quality and Outcomes Framework (2004)
Targeted to primary care practices
National scheme - voluntary (almost 100% adhesion by Y3)
Measures: Clinical (65%); administrative (practice organization); patient
experience; additional (contraceptive use, maternal and child health 
quite a difference with LIC where these are primary targets)
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Elsewhere?
 Australia
– PIP – Practice Incentive Programme for GPs (since 1990's)
– No aggregate score – each domain is separate
– Has not been adopted by GPs – complicated mechanism
 France
– CAPI (Contrat d'Amélioration des Pratiques Individuelles)
– April 2009
– Voluntary contract between the SHI and the GPs
 Netherlands (insurance companies); Spain (staff incentives); Sweden
(service contracts), etc.
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Performance Incentives in health – not much
happening in HICs?
 It seems that quite little happening outside a handful of countries …
 … but health workers in private and public sectors have been
influenced by the general result based reward system (most OECD
countries)
– Sectoral strategies in health have been implemented – not always a
success
 Also, in HICs more maybe happening at the micro level
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Who are targeted?
 Individual physicians (CAPI)
 Primary Care practices, physician networks (QOF, PIP)
 Hospitals (PHQID, IHA, etc.)
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Focus on quality of care in HICs
 HICs = general context of high utilization of health services 
basic difference with LICs
 High demand (social protection) but also supply (use of FFS
payment mechanisms)…
 … but studies showing that only ~50% of patients get adequately
treated (in the USA) – also big variations in care (Fisher et al.,
2002) (business as usual does not work)
 PI schemes = mitigation of the payment system incentives – from
quantity to quality (from curative to prevention)
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How is "quality" measured?
 Clinical quality
– Process indicators – adherence to care protocols (asthma,
diabetes, coronary heart disease)
– Intermediary outcomes (ex. blood pressure results for
hypertensive patients)
– (Outcomes) (patient mortality rates)
 Patient experience
– Surveys
– Consultation length
 Administrative processes
– Record keeping
– IT technology use
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Has it worked?
Some positive results …
CMS PHQID
UK QOF
Source: Campbell et al. 2007
… Petersen et al. 2006 : 12 /15 evaluation studies reported positive
results …
… but also some doubts:
"too little impact on provider behavior and not enough focus on demonstrable
benefit — including both health outcomes and spending" (Rosenthal 2008)
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Gaming, fraud, unwanted effects?
 There is little evidence of gaming or fraud from the HIC schemes
 Ex. in UK QOF the exemptions are seen as a possibility for
gaming but little evidence – some evidence on un-normally high
exemption rates (but not consistently) (Gravelle et al. 2007)
 Patient dumping in USA – some concerns but no evidence
(Rosenthal et al. 2007)
 No clear evidence on focusing on rewarded aspects of care
 When the income of the provider is already level the gain from
fraud is relatively little; and the fear of sanction is relatively high
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Some lessons learned
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Get the incentive path right
 The PI schemes have been sometimes implemented in a way that
leaves the incentive path unclear
– It is not always clear who should benefit
• Ex. the QOF targets practices, the nurses do quite a lot of the (routine) work
that affect the score but the GPs get the rewards
This has been creating some resentment among the nursing staff
Not enough going to investments
 In a larger organization (Hospital) several methods for translating
the incentives to staff have been used without any clear evidence
of which is the best
• Very rarely an individual bonus (or only to some key managers)
• Usually based on tightening of monitoring (sanctions)
• Most importantly : it is about informing everybody
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Who chooses the indicators?
 How to get a good deal (– good deal for who?):
– the QOF was a victory for the GPs (for the GP negotiators)  good
for GP income; results did follow; but is this value for money?
– In some US schemes providers have been less advantaged; some
schemes are cost-neutral from the payments point of view =
providers put some of their income at risk (and it worked)  better
deal for the payer (and it worked also); but will this work in the long
run?
– The French CAPI was not thoroughly negotiated with the GP
representatives (as QOF), we don't know yet what will happen but it
 The way the PI scheme is negotiated will have an impact on the
way it works
 But negotiations are the only way to get the providers to buy into
the system – there is quite a lot of resistance within providers –
and the schemes are voluntary
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How much should be paid?
(how to finance the LIC schemes in the future?)
 Performance incentives are not related to cost containment (at least
not immediately)
 QOF: in average £1bn/year (£17 pounds per hab.); ~£30 000 per
GP (20-25% of GP earnings from QOF) – explicit objective to raise
GP income
 USA: payments in average 1-2% of total reimbursements = 17$
/insured /month
 Big variations in the levels of payment – successful schemes with
low payments (PHQID) and high levels (QOF) - no clear evidence
on how much is enough – it seems that public reporting has a similar
effect than performance incentives
 Also some evidence from LIC that money is not the (only) mover
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Cost scenarios
Cost increase
Cost neutral
"New money"; Ex. QOF
Reallocation between interventions or providers
Return on investment
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Bonus optimization – return on investment
Using P4P to improve diabetes care
Based on the hypothesis of savings related to better care

Optimal reward =
$175 /patient/Y

Physician bonus=
$4300

1.5 $million net
benefit
Bridges to Excellence 2003-208, Five Years on : Bridges Built, Bridges to Build
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Reward mechanisms
 Improvements vs. attainment – both are used; but
there is an increase in using improvement measures
(at least in the USA)
 Improvement works better for low and high baseline
A combination of both seems to be the best way to go
•
If there are targets, how high should they be set? –
even high targets have been reached (when
compliance indicator) – quite a different question than
for example target of vaccinated children
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Reinforcing the purchaser role
 In LICs new type of internal purchasers are emerging – for ex.
insurances (private or public) – linked also to the user fee
question
 These purchaser (and pooling agents) can increase the use of
(curative) health services
 The use of performance incentives should be fitted in this
evolution – use performance incentives for preventive services,
but also for explicit quality incentives (a tool for strategic
purchasing)
 Epidemiological transition in LIC and MIC – using the PI schemes
for shifting attention to NCD related problems  the HIC
evidence give some promises also for the L/MICs
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References
 Campbell S., Reeves D., Kontopantelis E., Middleton E., Sibbald B., Roland M. Quality
of Primary Care in England with the Introduction of Pay for Performance. N Engl J Med.
2007;357(2): 181-190
 Fisher ES (2003). Medical care: is more always better? New England Journal of
Medicine,349(17):1665–1667.
 Gravelle, H., Sutton, M. and Ma, A. (2007), “Doctor behaviour under a pay for
performance contract: evidence from the Quality and Outcomes Framework”, Centre
for Health Economics
 Petersen LA, Woodard LD, Urech T, et al. Does pay-for-performance improve the
quality of health care? Ann Intern Med 2006; 145: 265-272.
 Rosenthal M.B. Beyond pay for performance – emerging models of provider–payment
reform. New England Journal of Medicine. 2008;359: 1197–200.
 Rosenthal M.B., Landon B.E., Howitt K., Ryu Song H.S., Epstein A.M. Climbing Up
The Pay-For-Performance Learning Curve: Where Are The Early Adopters Now?
Health Affairs. 2007;26(6): 1674–1682
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